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The American Journal of Managed Care March 2019
Fragmented Ambulatory Care and Subsequent Emergency Department Visits and Hospital Admissions Among Medicaid Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Incorrect and Missing Author Initials in Affiliations and Authorship Information
From the Editorial Board: Austin Frakt, PhD
Austin Frakt, PhD
Implications of Eligibility Category Churn for Pediatric Payment in Medicaid
Deena J. Chisolm, PhD; Sean P. Gleeson, MD, MBA; Kelly J. Kelleher, MD, MPH; Marisa E. Domino, PhD; Emily Alexy, MPH; Wendy Yi Xu, PhD; and Paula H. Song, PhD
Factors Influencing Primary Care Providers’ Decisions to Accept New Medicaid Patients Under Michigan’s Medicaid Expansion
Renuka Tipirneni, MD, MSc; Edith C. Kieffer, PhD, MPH; John Z. Ayanian, MD, MPP; Eric G. Campbell, PhD; Cengiz Salman, MA; Sarah J. Clark, MPH; Tammy Chang, MD, MPH, MS; Adrianne N. Haggins, MD, MSc; Erica Solway, PhD, MPH, MSW; Matthias A. Kirch, MS; and Susan D. Goold, MD, MHSA, MA
Did Medicaid Expansion Matter in States With Generous Medicaid?
Alina Denham, MS; and Peter J. Veazie, PhD
Access to Primary and Dental Care Among Adults Newly Enrolled in Medicaid
Krisda H. Chaiyachati, MD, MPH, MSHP; Jeffrey K. Hom, MD, MSHP; Charlene Wong, MD, MSHP; Kamyar Nasseh, PhD; Xinwei Chen, MS; Ashley Beggin, BS; Elisa Zygmunt, MSW; Marko Vujicic, PhD; and David Grande, MD, MPA
Medicare Annual Wellness Visit Association With Healthcare Quality and Costs
Adam L. Beckman, BS; Adan Z. Becerra, PhD; Anna Marcus, BS; C. Annette DuBard, MD, MPH; Kimberly Lynch, MPH; Emily Maxson, MD; Farzad Mostashari, MD, ScM; and Jennifer King, PhD
Common Elements in Opioid Use Disorder Guidelines for Buprenorphine Prescribing
Timothy J. Atkinson, PharmD, BCPS, CPE; Andrew J.B. Pisansky, MD, MS; Katie L. Miller, PharmD, BCPS; and R. Jason Yong, MD, MBA
Currently Reading
Specialty Care Access for Medicaid Enrollees in Expansion States
Justin W. Timbie, PhD; Ashley M. Kranz, PhD; Ammarah Mahmud, MPH; and Cheryl L. Damberg, PhD
Cost Differential of Immuno-Oncology Therapy Delivered at Community Versus Hospital Clinics
Lucio Gordan, MD; Marlo Blazer, PharmD, BCOP; Vishal Saundankar, MS; Denise Kazzaz; Susan Weidner, MS; and Michael Eaddy, PharmD, PhD
Health Insurance Literacy: Disparities by Race, Ethnicity, and Language Preference
Victor G. Villagra, MD; Bhumika Bhuva, MA; Emil Coman, PhD; Denise O. Smith, MBA; and Judith Fifield, PhD

Specialty Care Access for Medicaid Enrollees in Expansion States

Justin W. Timbie, PhD; Ashley M. Kranz, PhD; Ammarah Mahmud, MPH; and Cheryl L. Damberg, PhD
In a survey of community health center medical directors in 9 Medicaid expansion states and DC, nearly 60% reported difficulty obtaining new specialist visits and multiple access barriers on behalf of their patients.

Objectives: Community health centers (CHCs) historically have reported challenges obtaining specialty care for their patients, but recent policy changes, including Medicaid eligibility expansions under the Affordable Care Act, may have improved access to specialty care. The objective of this study was to assess current levels of difficulty accessing specialty care for CHC patients, by insurance type, and to identify specific barriers and strategies that CHCs are using to overcome these barriers.

Study Design: Cross-sectional survey, administered during summer 2017, of medical directors at CHCs in 9 states and the District of Columbia, all of which expanded Medicaid.

Methods: Surveys were administered to medical directors at 361 CHCs (response rate, 55%) to assess the difficulty of accessing specialty care by insurance type and to identify the specialties for which it was most difficult to obtain new patient visits. The survey also elicited ratings of commonly reported barriers to obtaining specialty care and identified strategies used by CHCs to access specialty care for patients. Descriptive results are presented.

Results: Nearly 60% of CHCs reported difficulty obtaining new patient specialty visits for their Medicaid patients, most often for orthopedists. Barriers to specialty care reported by CHCs included that few specialists in Medicaid managed care organization (MCO) networks were accepting new patients (69.4%) and MCO administrative requirements for obtaining specialist consults (49.0%). To enhance access to specialists, CHCs reported that they entered into referral agreements, developed appointment reminder systems, and participated in data exchange and other community-based initiatives.

Conclusions: Medicaid patients at CHCs face many barriers to accessing specialty care. Payment policies and network adequacy rules may need to be reexamined to address these challenges.

Am J Manag Care. 2019;25(3):e83-e87
Takeaway Points
  • Community health centers (CHCs) historically have reported barriers to specialists for their patients. CHCs in 9 states and the District of Columbia that expanded Medicaid eligibility reported challenges accessing specialty care for their patients, particularly for orthopedists, gastroenterologists, neurologists, and psychiatrists.
  • Barriers to specialty care reported by CHCs included that few specialists in Medicaid managed care organization (MCO) networks were accepting new patients (69.4%) and MCO administrative requirements for accessing specialist consults (49.0%).
  • In response to these and other challenges, CHCs are using a wide range of strategies to better integrate primary and specialty care services to provide more coordinated care to their patients.
Community health centers (CHCs) in the United States provide a primary care safety net to 25 million low-income patients annually,1 many of whom have complex health and social needs. CHCs predominantly deliver primary care and historically have reported challenges referring their patients for specialty care.2 Following expansions to Medicaid eligibility in 26 states and the District of Columbia (DC) in 2014, authorized by the Affordable Care Act (ACA), CHCs in many states treated a greater proportion of Medicaid enrollees and fewer uninsured patients.3

Medicaid eligibility expansions may affect CHCs in a variety of ways. Treating more insured patients may increase CHCs’ revenues, enabling investments in technology and staff to promote access to specialty care.4 Additionally, specialists may be more likely to accept referrals from insured patients. Conversely, all CHC patients may face barriers to specialty care, including shortages of specialists or their reluctance to accept Medicaid. Although some states have reported improved specialty access for Medicaid enrollees in recent years,4 a federal report from 2014 found that more than 40% of specialists surveyed did not offer appointments to Medicaid enrollees and the median wait time for specialty visits was twice as long as that for primary care visits.5 Overall, evidence on the ACA’s impact on access to specialty care is limited, with mixed results.6-8

Given this new policy landscape, in which CHCs located in Medicaid expansion states are providing services to a larger number of Medicaid enrollees who may or may not be able to access needed specialty care, we sought to understand current challenges and strategies used by CHCs to access specialty care for their patients in Medicaid expansion states. We conducted a survey of all CHCs that receive grant funding from the Health Resources and Services Administration (HRSA) in a sample of Medicaid expansion states to determine the specific specialties for which access problems were most acute, document the most common access barriers, and identify the strategies that CHCs are using to expand access to specialty care for their patients.


We surveyed medical directors at 361 CHCs in 9 Medicaid expansion states and DC during summer 2017 (response rate, 54.6%). CHCs, a type of federally qualified health center, are nonprofit, community-focused primary care providers that are located in medically underserved areas and provide services to all patients, regardless of ability to pay.9 Most CHCs receive grant funding from HRSA. CHCs with and without federal funding collectively serve 1 in 6 Medicaid enrollees.10 The study sample included California, Colorado, DC, Illinois, Louisiana, Minnesota, New Jersey, Oregon, Vermont, and Washington (average state-level response rate, 58.9%; range, 26.3% [New Jersey] to 78.6% [Minnesota]). The survey was fielded as part of a larger effort to describe the landscape of care integration activities involving CHCs, specialty practices, hospitals, and social service organizations in 12 states and DC. The study was approved by RAND’s Institutional Review Board.

The web-based survey was completed by the medical director or a designee at each CHC. The survey included items that solicited ratings of difficulty for their patients to access timely initial visits with specialists outside of CHCs, by payer, using a 5-point Likert-type response scale with the options of very difficult, somewhat difficult, neither easy nor difficult, somewhat easy, or very easy. Timely access was not explicitly defined because states often use different standards.11 Respondents reporting that it was very difficult or somewhat difficult were asked to report, by payer, the 1 specialty for which it was most difficult to access new patient visits. Respondents were provided a drop-down menu of 16 specialties and were given the option to write in a specialty not listed.

CHCs also responded to questions about 12 barriers to obtaining specialty care (not specific to payer), identified from both a review of the literature and discussions with 15 stakeholders during an earlier phase of the project.2,12-16 Survey respondents also answered 17 questions about strategies that might be used to access specialty care for patients (not specific to payer) related to alternative care delivery models (eg, telemedicine), data-sharing arrangements, and participation in activities that are likely to strengthen linkages with specialists. The items were measured using a 6-point Likert-type response scale with the options of not applicable, never, rarely, sometimes, often, or always. CHCs responding “not applicable” were not included in the results for that item. Based on the distribution of survey item responses, results are presented with responses dichotomized to often/always versus never/rarely/sometimes (or, for some items, very difficult/somewhat difficult vs neither easy nor difficult/somewhat easy/very easy).

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